WHO Commission on Social Determinants of Health Globalisation and Health: Pathways of Transmission and Evidence of Impact
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Globalization and Health Knowledge Network: Research Papers WHO Commission on Social Determinants of Health Globalisation and Health: Pathways of Transmission and Evidence of Impact Globalization Knowledge Network Giovanni Andrea Cornia Stefano Rosignoli Luca Tiberti Pathways of transmission and evidence of impact 1 Preface The Globalization Knowledge Network (GKN) was formed in 2005 with the purpose of examining how contemporary globalisation was influencing social determinants of health. It was one of nine Knowledge Networks providing evidence-informed guidance to the work of the World Health Organization’s Commission on Social Determinants of Health (2005-2008): like most of the Knowledge Networks, its operations were financed by an external funder (in this case, the International Affairs Directorate of Health Canada, Canada’s national ministry of health). The GKN conducted two face-to-face meetings to debate, discuss, outline and review its work, and produced thirteen background papers and a Final Report. These papers and the Final Report underwent extensive internal and external peer review to ensure that their findings and policy inferences accurately reflected available evidence and scholarship. This GKN publication series was prepared under the general editorship of Ronald Labonté, with assistance from Vivien Runnels and copy-editing provided by Wayne Harding. All views expressed are exclusively those of the authors. A complete list of titles in the publication series appears on the inside back cover of this monograph. Globalization Knowledge Network Ronald Labonté (Chair) Ted Schrecker (Hub Coordinator) Layout and Design: Rhonda Carscadden: rhocaDESIGNS.com Globalization and Health Knowledge Network: Research Papers Globalisation and Health: Pathways of Transmission and Evidence of Impact1,2,3 WHO Commission on Social Determinants of Health Authors: Giovanni Andrea Cornia University of Florence and Istituto regionale programmazione economica della Toscana (IRPET) Stefano Rosignoli Istituto regionale programmazione economica della Toscana (IRPET) Luca Tiberti University of Florence 1 A prior version of this paper was presented on 27 November 2006 at a meeting of the Globalization Knowledge Network of the WHO Commission on Social Determinants of Health held in Kievits Kroon Country Estate, Gauteng, South Africa. The authors would like to acknowledge the comments received on that occasion from Patrick Bond, Corinna Hawkes, Ronald Labonté, David Sanders, Ted Schrecker, and Rolph van der Hoeven. The authors are also much indebted to Roberto De Vogli for his early suggestions on the structuring of the paper, and for comments he provided on its first draft. Many thanks go also to Patrick and Silvyane Guillaumont and other participants to the Development Seminar held at CERDI-University of Clermont Ferrand in December 2006 for the comments provided on the first draft of this paper. Our heartfelt thanks go also to Sheila Marnie who assisted with the editing of the text. 2 The empirical sections of this paper are based on the Globalisation-Health Nexus Database (GHND). A prior version of GHND was compiled in May 2004 with the financial support of the McArthur Foundation. 3 This paper was commissioned and financially supported by the WHO Commission on Social Determinants of Health (http://www.who.int/social_determinants/ en/). Table of contents Preface 2 Table of acronyms 8 1. Introduction: background, purpose and method of analysis 9 2. Globalisation defined 12 2.1 Endogenous determinants of globalisation 12 2.2 Exogenous (or policy-driven) determinants of globalisation 13 2.3 Actors of exogenous globalisation 14 3. Mortality trends during the recent globalisation 16 3.1 A slow down in the pace of improvement in health status 16 3.2 Changes in the distribution of health and well-being across and within countries 18 4. Mortality models 22 4.1 Material deprivation 23 4.2 Progress in health technology 27 4.3 Acute psychosocial stress 27 4.4 Unhealthy lifestyles 29 4.5 Income inequality, hierarchy and social disintegration 30 4.6. Random shocks 31 4.7 Summary of variables affecting mortality by the five main pathways 32 5. Changes in the social determinants of health: 1980-2005 compared to 1960-80 34 5.1 Household Income 34 5.2 Income subsidies 36 5.3 Economic instability 37 5.4 Income inequality 40 5.5 Trends in formal and informal employment and in unemployment 43 5.6 Inflation and prices of basic goods 44 5.7 Taxation, public expenditure on health care, and approaches to its financing 45 5.8 Migration and family arrangements 48 5.9 Technical progress in health 49 4 Globalization and Health Knowledge Network 5.10 Fertility rates and dependency ratios 51 5.11 Smoking, drinking and obesity 51 5.12 Exogenous developments and random shocks 53 6. Econometric estimates of LEB, IMR, U5MR models 55 6.1 The GHND dataset 55 6.2 Descriptive statistics and bivariate correlation between main variables 57 6.3 Model specification and regression plan 58 6.4 Global results 60 6.5 Regional results 66 7. Simulation of LEB changes due to globalisation & shocks 70 8. Impact of liberalisation-globalisation on the determinants of health 74 8.1 Introduction 74 8.2 Methodological problems and data sources 74 8.3 Results from the literature 76 8.4 Econometric results 77 9. In lieu of conclusions 80 References 83 List of figures Figure 1. Relation between smoking incidence among 20-55 years old males and LEB 30 Figure 2. Standard deviation of GDP growth rates, 1950-2001 36 Figure 3. Number of financial crises, 1975-2002 38 Figure 4. Changes in male life expectancy at birth in relation to a stress index summarizing changes in unemployment, labour turnover and family completeness, Russia, 1989-1993 40 Figure 5. Trends in the Gini coefficients of income inequality in China and household disposable income in Great Britain, 1960-2003 42 Figure 6. Changes in inequality and suicide rate in transition countries, 1989-97 45 Pathways of transmission and evidence of impact 5 Figure 7. Inflation spline (i.e. the median inflation of countries examined) for the period 1960-2002 45 Figure 8. Trend in the ‘food-price/consumer price’ index by country groups1980-2005 45 Figure 9. Average un-weighted tariff rates (in percent) by region, 1980-1998 46 Figure 10. DPT3 Percentage immunization rate, 1980-1999 49 Figure 11. Trends in alcohol consumption by region 52 Figure 12. Number of conflicts in the last decades 1960-2002 53 Figure 13. Elasticities of the explanatory variables’ coefficients on global estimates for LEB 62 Figure 14. Relation between inequality and LEB, 1960-1980 and 1980-2005 63 Figure 15. Observed and fitted median spline of world LEB 64 Figure 16. LEB elasticities of explanatory variables for four country groups 68 Figure 17. Trend in the observed and estimated of the median spline of the life expectancy at birth in the four sub regions 69 Figure 18. Correlation between the real interest rate and the Gini coefficient of income inequality 77 List of tables Table 1. Evolution of the Washington Consensus 13 Table 2. Average annual population-weighted a rates of change b of (100-LEB) and IMR, 1960-2004 17 Table 3. Trends in the coefficient of variation and Gini coefficient of the intra-regional and global distribution of 100-LEB, 1960-2000 20 Table 4. Proportional mortality by main disease groups and selected causes, 2001 23 Table 5. Summary of variables affecting health status by main mortality model 33 Table 6. Period GDP/c growth rates* by main regions, 1960-2005 35 Table 7. Share of countries (by region) which experienced negative growth of GDP/c 35 Table 8. Public subsidies /GDP, selected years 37 Table 9. Percentage of households in each income decile receiving different subsidies, Viet Nam 1993 and 1998 37 Table 10. Average standard deviation of GDP/c growth rate by country groups 1960-2005 38 6 Globalization and Health Knowledge Network Table 11. Number of banking and financial crises 39 Table 12. Trends in the Gini coefficients of the distribution of income from the 1950s to the 1990s for 85 developed, developing and transitional economies 41 Table 13. Trends in central government revenue/GDP ratio 43 Table 14. Access to health care and financial difficulties in China, 1993 and 1998 48 Table 15. Cardiovascular interventions* in OECD countries (DDD/1000 inhabitants/day) 49 Table 16. Prevention of mother-to-child transmission with antiretroviral prophylaxis 50 Table 17. Average population-weighted Total Fertility Rates by region, 1960-2005 52 Table 18. Summary of main variables included in GHND and used in regression analysis 56 Table 19. Overlap between geographical and cluster classifications of country groupings 57 Table 20. Descriptive statistics for the variables used in the regression analysis 58 Table 21. Correlation matrix of selected variables included in estimation of the global model 60 Table 22. Results of worldwide regression analysis for 1960-2005 on LEBa, IMR, U5MR 61 Table 23. Results of the regression analysis on LEB, IMR, U5MR for high and middle income countries, 1960-2005 65 Table 24. Results of the regression analysis on LEB, IMR, U5MR for low income and transitional economies, 1960-2005 67 Table 25. Gains and losses of LEB years by 2000 due to policy changes, endogenous changes and random shocks during 1980s-1990s 72 Table 26. Results of the regression of the Lora’s Overall Reform Index on income inequality, GDP/c and volatility of GDP/c 79 Pathways of transmission and evidence of impact 7 Table of Acronyms AWC Augmented Washington